Organisation objective

• Governance

Working with people and communities

What approaches have been used to ensure people and communities have informed this programme of work?

• Qualitative data and insight, for example, national surveys; complaints.

The purpose and remit of the New NHS England Programme has been informed by the NHS Operating Framework and NHS Long Term Plan.

Action required

This paper summarises the progress and benefits achieved to date, and the lessons learned from the New NHS England Change Programme, as well as the next steps proposed.

The Board is asked to endorse the following recommendations:

i. The New NHS England Committee should be closed after its 2 May 2024 meeting, reflecting delivery of its objectives and transition to ownership of ongoing actions by the NHS England Executive, and the Chief Delivery Officer (CDO) as Programme Senior Responsible Officer.

ii. The NHS England Executive assume accountability for delivery of other areas of work, with appropriate board committee oversight, including but not limited to, our Organisational Design and Culture Programme and establishing an internal improvement team.

iii. This will be supported by a small programme team, reporting to the CDO, to:

1. complete final design and implementation work, including the redesign, consultation and implementation of future internal capability and capacity we need for human resources and organisational development
2. support and influence cross-organisation changes in ways of working to embed implementation of NHS England’s operating framework
3. oversee the Filling of Posts, Recruitment, Establishment Control and Electronic Staff Record Rebuild and Optimisation projects, supporting transition to improved business-as-usual establishment control and resourcing processes
4. monitor benefits realisation and determine the most suitable delivery model for implementing the recommendations from the lessons learned work.

iv. There are planned internal and external communications about the completion of the New NHS England Programme, sharing our learning and planned next steps

Background and context

1. Following decisions by the Secretary of State for Health and Social Care, the New NHS England Programme has worked with colleagues across the organisation to manage the merger of Health Education England with NHS England, NHS Digital and NHSX, organisations with a combined 24,227 whole time equivalent posts.

 2. NHS England’s Board endorsed the ambition to create a smaller, high performing organisation, delivering the best value for money, that could lead the NHS more effectively for patients. A new committee of the NHS England Board was established, to oversee the work of the programme and delivery of its objectives.

3. This change programme has been one of the largest public sector transformations in the UK. The restructuring has created a new organisation that is 30% smaller than its predecessor organisations combined (over 36% smaller when taking account of transfers functions and staff out of NHS England). Importantly, it has also brought national responsibilities for people, policy and strategy and technology across the NHS, together into one organisation for the first time which will improve decision making and delivery.

4. It been a long and challenging process for our staff due to the scale and timeframe of this change programme, and this has undoubtedly had a significant impact on morale. Despite this, a significant proportion of NHS England’s plan for 2023/24 was delivered due to the efforts of our teams. While there has been extensive feedback on the transactional changes which were necessary to deliver a new NHS England, we also need to realise the opportunity to further transform and improve the way we work internally and with the wider system. This requires us to focus on our culture and ways of working so that we can be most effective at supporting our frontline colleagues to improve care for patients, and ensuring the activities we undertake add value to patients and staff. There are a range of actions that leaders and colleagues across the organisation need to take, to sustain and build on improvements achieved so far and realise true transformation in NHS England’s ways of working.

Progress made against our objectives

5. Three overarching objectives were established at the start of the programme which have guided the design. High-level reporting is set out below on these core objectives. The objectives have largely been met, although our work on the culture of our new organisation has not progressed as far as was hoped, in part because of the focus on the immediate transactional task of restructuring.

Objective 1 – optimise the size and shape of the future NHS England

6. The commitment that by April 2024 the new single organisation would be at least 30%, and up to 40%, smaller than the former NHS England, Health Education England and NHS Digital combined has been achieved. Once the final transfers of staff and functions out of NHS England have taken place, the organisation will have reduced by over 36%.

7. The design approach was guided by a set of principles and a commitment that the restructuring process would not impair the diversity of the organisation. Monitoring up to the end of February 2024 has shown an increase in colleagues with protected characteristics relating to ethnicity and disability, with no change for colleagues who report their sexual orientation as lesbian, gay or bisexual.

Objective 2 – minimise organisational complexity with integration of common functions, and create a consistent and streamlined change delivery organisation

8. We set out to create a smaller, integrated and more streamlined organisation to deliver our Operating Framework.

9. Our focus has been on eliminating siloed working, creating clear single functional homes for key functions (eg data and analytics and communications), and the rationalisation of programmes to create a well-defined and realistic portfolio of coordinated programmes with clear responsibilities at national, regional and system levels.

Objective 3 – facilitate more effective internal enablers to support service delivery

10. The organisational development and culture work has focused to date on our purpose – to lead the NHS in England to deliver high-quality services for all. As the organisation moves into our final new structures a refocused organisational development and culture delivery plan has been established to provide firm foundations for this work.

Benefits

11. An analysis of the benefits delivered to date, and those that will be realised in the future, has been completed. It shows that while significant financial and operational benefits have been realised, some benefits of the merger will be delivered over the coming years, particularly in the areas of system working, equality, diversity and inclusion and organisational development and culture.

12. Below is a summary of the benefits review mapped against 5 themes.

Financial

13. We have successfully delivered a smaller organisation that will cost less to support the wider NHS and will provide greater value for money to taxpayers. The new organisation has an establishment of circa 15,300 whole time equivalent staff compared with a combined 24,300 whole time equivalent staff for the legacy NHS England, Health Education England and NHS Digital. The smaller organisation will facilitate a reduction in running costs over time in a range of areas such as estates, IT and travel and subsistence.

Operational

14.The new NHS England is a leaner, more focused organisation set up to make efficient use of resources, and removing duplicated resources and roles, for example, internal corporate services have been centralised. The new structure focuses on improving co-ordination between teams within NHS England and integrated care boards and providers. Smaller national directorates provide support and expertise to enable improvement and drive transformation across the NHS.

15. A joined-up approach to digitally enabled transformation has been realised by bringing together digital, policy and system oversight expertise. The benefits of this approach are clear in our work to secure additional investment in technology, which will allow the NHS to drive digital improvements, releasing time to spend with patients and enable joined up care across services. 

16. Aggregating functions and resources provide economies of scale and requires less co-ordination. For example, the Transformation Directorate is providing standards, professional development, support and oversight for all digital, data and technology services and professionals, reducing siloed working. The directorate also brings together internal IT and data, delivering essential collaboration projects that have been consolidated and optimised to make valuable cost savings.

System working

17. Transforming how NHS England teams and systems interact to reflect the integrated way integrated care boards work has been enabled by redesigning our teams to manage current and forecast requirements of the organisation. New ways of working offer greater agility, without increasing headcount or compromising outcomes. This is underpinned by agreed principles for setting priorities through business planning. 

18. Rationalisation of programmes within NHS England has created a clearly defined programme portfolio with clear system responsibilities.

Organisational development and culture

19. An Organisational Development and Culture Programme has been developed to support the organisation to improve our ways of working and remain focused on how we can best support the NHS. Our work on organisational development and culture is key to transforming our ways of working and will focus on putting in place the right tools and support; approach to performance management, and; improved collaboration tools, so that we enhance co-ordination across the organisation.

Equality, diversity and inclusion

20. As set out in paragraph 7, monitoring up to the end of February 2024 has shown an increase in colleagues with protected characteristics relating to ethnicity and disability, with no change for colleagues who report their sexual orientation as lesbian, gay or bisexual. Annex A shows the analysis of protected characteristics from the point of announcing the change programme in July 2022 to the end of February 2024.

21. As part of the wider equality, diversity and inclusion improvement plan for NHS England, 7 priority areas have been identified to drive and improve equality, diversity and inclusion in the new organisations. In addition, a new approach for diversity representation in the organisation will reflect local working populations as well as current diversity levels in regions and directorates. 

Lessons learned

22. As part of completing the change programme, a lessons learned analysis was carried out. Feedback indicates that while significant transactional changes have taken place, further transformational, behavioural and organisational development changes are still required to improve and embed new ways of working.

23. There are a range of actions that need to be taken to enable our new ways of working. These include but are not confined to:

a. integrating business planning, to ensure that the new organisation can work in a joined up and agile way to reallocate resources in response to a prioritised set of objectives

b. fostering a positive organisational culture where employees understand their unique role in supporting the NHS, feel engaged, appreciated and motivated to retain and attract talent; continuing to get feedback from colleagues across the organisation; and illustrate how feedback will be translated into actions

c. setting new ambitions to cultivate diversity of experience and thinking in NHS England, to ensure there is more diverse representation across protected characteristics

d. adopting the components of NHS IMPACT within NHS England itself and in our work with the wider system

e. ensuring greater agility in responding to priorities, and streamlining our asks of systems and providers and ensure that NHS England activities add value and are in service of patients, taxpayers and NHS organisations.

24. Colleague feedback will continue to be used to inform our approach and help to achieve true transformation in NHS England’s ways of working.

Next steps

25. Attempting to merge 5 separate organisations, significantly downsize and transform how we operate, all at the same time has proved challenging and there remains work to do to transform our ways of working. It is important, now the transactional people change element of the programme comes to a close, that there is a sustained focus on organisational transformation, our ways of working and our new culture.

26. Whilst the New NHS England Committee will cease following its 2 May 2024 meeting, there remain key actions that need to endure; these will transition to ownership by the NHS England Executive, and the Chief Delivery Officer as Programme Senior Responsible Officer.

27. A core programme team will remain in place, reporting to the CDO, to: 

a. complete final design and implementation work, including the redesign, consultation and implementation of our human resources and organisational development function

b. support and influence cross-organisation changes in ways of working to enable implementation of NHS England’s operating framework

c. oversee the Filling of Posts, Recruitment, Establishment Control and Electronic Staff Record Rebuild projects, supporting transition back to business-as-usual establishment control and resourcing processes

d. monitor benefits realisation and determine the most suitable delivery model for implementing the recommendations from the lessons learned work. 

28. The NHS England Executive will also assume accountability for delivery of other areas of work, with appropriate board committee oversight, including but not limited to, our Organisational Design and Culture Programme and establishing an internal improvement team.

29. Our organisational development and culture plan and internal improvement resource will be critical to driving new ways of working and integration, challenging siloed working and providing an environment where our staff can deliver their best work. Developing this new culture, supported by new ways of working, will be key to inspiring our new teams, so NHS England meets the needs of the NHS, now and in the future.

Annex A

Tables 1 to 4 show the analysis of protected characteristics from the point of announcing the change programme in July 2022 to the end of February 2024.

Table 1: comparison of ethnicity data (July 2022 to February 2024)

 Table 2: comparison of gender data (July 2022 to February 2024)  

 Table 3: comparison of disability data (July 2022 to February 2024)

 Table 4: comparison of sexual orientation data (July 2022 to February 2024)    

Publication reference:  Public Board paper (BM/24/22(Pu)